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This survey asks for your opinions about resident safety issues in your nursing home. It will take about 15 minutes to complete.
If a question does not apply to your job or you do not know the answer, please mark the box in the last column. If you do not wish to answer a question, you may leave your answer blank.
- In this survey "resident safety" means preventing resident injuries, incidents, and harm to residents in the nursing home.
Section A: Working in This Nursing Home |
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How much do you agree or disagree with the following statements?
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Section B: Communications |
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How often do the following things happen in your nursing home?
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Section C: Your Supervisor |
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How much do you agree or disagree with the following statements?
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Section D: Your Nursing Home |
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How much do you agree or disagree with the following statements?
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Section E: Overall Ratings |
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I would tell my friends that this is a safe nursing home for their family. |
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Please give this nursing home an overall rating on resident safety. |
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Section F: Background Information |
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What is your job in this nursing home? Check the box that best applies to your job. If more than one category applies, check the highest level job. |
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How long have you worked in this nursing home? |
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How many hours per week do you usually work in this nursing home? |
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When do you work most often? |
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Are you paid by a staffing agency when you work for this nursing home? |
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In your job in this nursing home, do you work directly with residents most of the time? |
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In this nursing home, where do you spend most of your time working? |
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| Section G: Your Comments
Please feel free to write any comments about resident care and safety in this nursing home. | | |
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